AUCTORES
Globalize your Research
Case Report | DOI: https://doi.org/10.31579/2690-1897/017
1Professor and Head, Department of Surgery, Imperial hospital, (IHL) Chattogram.
2Associate Professor and Head, Department of pathology, Jahurul Islam Medical College (JIMC), Bajitpur, Kishoreganj.
3Registrar, Department of surgery, IHL.
4Registrar, Department of Surgery, JIMC
*Corresponding Author: Sardar Rezaul Islam, Professor and Head, Department of Surgery, Imperial hospital, (IHL) Chattogram: E-Mail: islamreza@hotmail.com
Citation: Sardar Rezaul Islam. (2020) Metastatic Mixed Germ Cell Tumor Presented With Hemoptysis- A Case Report.journal of Surgical Case Reports and Images, 3(1): Doi: 10.31579/2690-1897/017
Copyright: © 2020. Sardar Rezaul Islam. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 20 January 2020 | Accepted: 28 January 2020 | Published: 31 January 2020
Keywords: Testicular cancer; mixed germ cell tumor; Seminoma; Choriocarcinoma; Pulmonary metastasis; Hemoptysis.
A 35 year’s old male presented with right testicular swelling for last six month. He developed hemoptysis and mild dyspnea for 2 weeks. Ultrasonography revealed testicular malignancy with multiple heterogenecity. CT scan of the abdomen did not reveal any lymph node metastasis. His X-ray chest showed extensive pulmonary metastasis. All three tumor markers were raised. Histology was suggestive of mixed germ cell tumor with a rare combination of Seminoma and Choriocarcinoma. Because of this rare combination of 2 varieties of testicular germ cell tumor and advanced systemic metastasis we presented this case.
Primary testicular tumors are the most common solid malignant tumor in men between the ages of 20 and 35 years. For unknown reasons, the incidence of this cancer has increased during the last century. Most testicular tumors are derived from the germ cells of the testis, although about 5% of testicular tumors are derived from other cells, including Leydig cells and lymphocytes (lymphoma).
The cause of testicular tumors is unknown, but several predisposing factors are recognized. Cryptorchidism, genetic susceptibility, family history, and past history of testis cancer have been reported as the important risk factors. Their incidence has increased over the past century. Ninety-five percent of testis tumors originate from germ cells while the remaining 5% are Leydig cell tumors and lymphomas (1). Germ cell tumors can be broadly classified as seminomatous and non-seminomatous. Approximately 60% of germ cell tumors are mixed germ cell tumors (2). Painless swelling or nodule in testis is usually the most common symptom. However, metastasis-related symptoms may be the first presenting symptom (3). We report a patient diagnosed with mixed germ cell tumor presenting with hemoptysis and mild dyspnea due to massive lung metastasis.
Any solid, firm mass within the testis should be considered testicular cancer until proven otherwise. Prompt diagnosis and early treatment are required for cure. Testicular cancer may be painless, in which case they are sometimes ignored by the patient. In patients with scrotal pain, testicular cancer must be differentiated from epididymo-orchitis. The clinician should consider the full differential diagnosis of a testicular mass, which includes epididymo-orchitis, testicular torsion, hydrocele, hernia, hematoma, spermatocele, varicocele, and syphilitic gumma.
In the past, metastatic testicular cancer was usually fatal, but recent advances in treatment, including high-dose chemotherapy and stem cell rescue, have considerably improved the prognosis. Indeed, testicular cancer is a bright spot in the oncological landscape and are now considered to be the model for treatment of solid tumors.
A 35 years old male presented with six month history of painless swelling of the right testis. He ignored this swelling. He developed hemoptysis and mild dyspnea for two weeks. He did not complain of any abdominal pain. On examination his right testis was swollen, firm to hard in consistency and having smooth surface. It was oval in shape but size was about 8cm/5 cm (Fig-1). The testis was not fixed with the scrotal wall. Ultrasonography showed a right testicular mass with multiple heterogenecity. There was no fluid collection in the scrotum. CT scan of the abdomen did not reveal any lymph node enlargement. His chest x-ray showed an extensive multiple cannon ball appearance on both lung fields (Fig-2). His serum marker was done. His α-feto protein was >1000 U/ml (range0.5-5U/ml) ß-HCG was 399U/L (normal<10>
Non-seminomatous germ cell tumors are highly aggressive malignancies of the testis. Histologically, approximately 70% of the non-seminomatous germ cell tumors are composed of more than one germ cell component, which is called mixed germ cell tumor. Several studies have reported specific combinations of different elements in mixed GCT of testis [4, 5]. Mostofi [5] in classifying more than 6000 testicular tumors found >1 histological patterns in approximately 60% of cases with the most frequent combination of embryonal carcinoma, yolk sac tumor and choriocarcinoma. Statistical analysis of possible combinations by Mosharafa et al. revealed 10 possible pair combinations. Complete diagnosis requires obtaining an appropriate specimen for making the correct diagnosis together with the correlation of the serum tumor markers. This is important for staging and also for postoperative follow up and to know the response of the treatment and surveillance. α-fetoprotein (AFP) is produced by the yolk sac elements and is elevated in 50-70% of NSGCT. It is not usually elevated in pure seminoma. Its half-life is about 5 days. β-human chorionic gonadotrophin (β-HCG) is produced by trophoblastic elements in the tumor. It is raised in 40 to 60% of NSGCTs and in up to 30% of pure seminomas. It has a half-life of 1 day. Lactate dehydrogenase (LDH) is less specific, but is more common in seminoma. Overall, 90% of NSGCTs elaborate at least one tumor marker, while markers are elevated in <40>
Choriocarcinoma is relatively rare among the various components of non-seminomatous germ cell tumors, including embryonal carcinoma, seminoma, yolk sac tumor and teratoma. Less than 8% of the testicular germ cell tumors contain a choriocarcinoma component, and pure choriocarcinoma accounts for only 0.3% of all the primary testicular germ cell tumors [6].
The term choriocarcinoma is generally used to refer to gestational choriocarcinoma, which most commonly occurs with hydatidiform mole. It is a cancer that typically occurs in the chorionic epithelium of the placenta of females and it rarely occurs in males. Choriocarcinoma in the testis has a particularly high-risk histology and the patients with this tumor are prone to present with metastases rather than a testicular mass. The most common presenting symptoms include hemoptysis secondary to pulmonary metastases, back pain secondary to retroperitoneal spread, gastrointestinal bleeding due to gastrointestinal tract metastases and neurological symptoms that are due to brain metastases [7].
Yokoi K et al. recently reported a review of the literature on choriocarcinoma [6]. They examined the characteristics of this tumor based on 106 cases of male choriocarcinoma that were reported during the previous 12 years (1995 to 2005). The testis was the most common primary site at 33% (35/106), followed by the mediastinum, pineal body, gastrointestinal tract, lung and retroperitoneum. Metastasis was seen in 83% of the patients, with multiple metastases seen in most of the patients. The most common metastatic sites were the lung, liver and brain. The mean age of the males with choriocarcinoma was 36.0 years, and this tumor tended to occur in children and adolescent, where the age of two thirds of all the cases (69/106) was less than 30-years old. The prognosis of male choriocarcinoma was very poor, with the cumulative survival rate being 30%, and the course of the disease was rapid with the mean survival time being 7.7 months; 23.8% and 45.4% of the patients showed 1-month and 6-month mortality, respectively [6].
Patients with advanced choricocarcinoma have a worse prognosis than do the patients with other advanced/poor prognosis non-seminomatous GCTs because of the very high levels of hCG and the propensity for pulmonary and non-pulmonary visceral metastases [8]. Jensen and Venner [9] presented data from a population of 77 advanced germ cell patients who were treated with cisplatin-based therapy, and 3 of 77 patients had pure choriocarcinoma. All the three patients with pure choriocarcinoma died. The recurrent pure choriocarcinoma also has a very poor prognosis. There has been a report on a large series from Indiana University of 135 patients with GCTs and these patients failed after the first-line, platinum-based therapy, and the patients were treated with standard salvage chemotherapy with vinblastine, ifosfamide and cisplatin. Thirty-two patients were long-term survivors, but all the seven choriocarcinoma syndrome patients died . However, Papiani and Einhorn [9] reported that long-term survival and a potential cure was possible with high-dose chemotherapy in the patients with recurrent choriocarcinoma. The patients with choriocarcinoma who fail to achieve a complete response (CR) to the first-line therapy (the so-called incomplete responders) have a less than a 10% likelihood of long-term survival with the second-line chemotherapy [10,12]. We could not follow up the patient regarding response to the chemotherapy as he was transferred to a cancer institute for further treatment.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
